10 Questions: E. Wesley Ely, MD, MPH

What's the biggest barrier to practicing medicine today? That's just the first of the 10 Questions the MedPage Today staff is asking leading clinicians and researchers to get their personal views on their chosen profession. In this series we share their uncensored responses. Here, answers from E. Wesley Ely, MD, MPH.

Ely is a pulmonary and critical care expert at Vanderbilt University Medical Center in Nashville, Tenn. He founded the ICU Delirium and Cognitive Impairment Study Group there and has been a driving figure in research on sedation and delirium in the ICU and cognitive impairment after critical care.

1. What's the biggest barrier to your practicing medicine today?

I think in the area of critical care, it's really seeing people too late. People delay coming in for many reasons: It could be cultural, it could be educational, it could be because of fear they're going to incur pain if they come in and get a workup. A lot of times they're afraid of the financial implications, or they could just be in denial. I really want to see my patients earlier in the course of their illness because when they come in so late, there's much less we can do for them.

2. Which is your most vivid memory involving a patient?

So many people flash in front of my face when you ask me that question. But I remember this one elderly couple. The man came in with severe sepsis. He was infected, had pneumonia, and they both disallowed us from providing routine medical care and eventually life support. It wasn't because they didn't value his life, but because they were worried about the financial implications -- not being able to afford the care they were going to receive and how it might have downstream implications for their family. The reason it's such a vivid memory is that eventually we managed to convince them to let us care for them the way we would care for anyone, regardless of money. And I remember seeing him in clinic a couple of months later -- he came across the room smiling and happy and thankful that he had not let that stop him from getting care for his infection.

3. What do you most often wish that you could say to patients but don't?

You look at these people suffering, and I've always wanted to tell them how the suffering they're going through is helping me as a person. But as a physician I don't want to make it about me, I always keep it about them, of course, because I'm there to serve them. So I don't say that; but it's a mixed gift to me from the patients -- specifically by my witnessing what they're going through and how they handle it.

4. If you could change or eliminate something about the healthcare system, what would it be?

My answer to this question has certainly have evolved over time. Right now, I think the most important thing that I would change is to preserve what has been taken away from the field of medicine. And it has everything to do with the words "physician" and "provider." The modern term "provider" really risks stripping the profession of medicine of some of the most key elements that we as physicians need to be employing in our relationships with our patients. A physician has to exert judgement and morals. And our decisions with these complicated thought processes are part of caring for another human being. We're stripping it down or watering it down to the term provider. It just means that I would become an automaton providing whatever I'm asked to provide, and I think it completely undermines the entire profession. For me to maintain the commitment and the integrity that I must have in the relationship with my fellow men and women that I'm caring for, I have to be a physician and not merely a provider.

5. What is the most important piece of advice for med students or doctors just starting out today?

It's really about maintaining a balance of not just what your content knowledge is, but also your physical and spiritual health. Whatever you think is appropriate, best for you, physically and spiritually, that oftentimes gets left behind when you go into medical school and enter into a busy practice. And you really risk not only your own health and happiness but certainly that of your patients. Because you cannot provide the best care for your patients you need in that healing process if you are not as healthy, physically and spiritually, as you should be.

6. What is your "elevator" pitch to persuade someone to pursue a career in medicine?

If I were to pursue an elevator pitch with anybody about medicine, it would certainly be about focusing their mind away from the issues of money and billing and administrative components of medicine. I have to ask you: What is it that you love to do? Are you good at science? Because science is involved in medicine. But do you also have that second key component that medicine has to have, which is interest in serving your fellow men, the human who's suffering? If a person loves science and has that skill of acquiring that knowledge, and they love serving other people and want to make that their devotion, now you have the makings of a vocation. And that person could be great in medicine.

7. What is the most rewarding aspect of being a doctor?

Well, it's not about choosing the right drug or about making the mystery diagnosis. It's about the human connection. The chemistry between people that you watch unfold in the midst of an illness. When someone comes in and is suffering from their injury or their disease, it's initially perceived as something negative. And then you as a physician get to enter into this very intimate time in their life, and along with their family, watch that pain and suffering translate into the healing process. And I don't mean just healing of the body but healing of the relationships. And this very deep and priceless experience that people go through as they're getting on the other side of an illness. Or even if they're going through the dying process and you can't cure them. This to me is by far the most valuable and privileged piece of being a physician and practicing medicine.

8. What is the most memorable research published since you became a physician and why?

Memorable is the key word, since everything that we've been talking about here has to do with memory. Healing and getting back to the person that you were before illness or injury has everything to do with your brain and how it's working. And to me the most memorable research is really a couple of New England Journal of Medicine papers. One by Terri Fried published in 2002, which largely led to the past decade of work that our group, the ICU Delirium in Cognitive Impairment Study Group, has done. She found, in a large study of people coming in with serious illness, that 90% did not want to go through the throes of major medical interventions trying to heal them if they were left cognitively impaired. This really got me scratching my head as an ICU doctor, as an intensivist. What if we're leaving our patients with cognitive impairment after their critical care experience? What implications would that have on their decisions to undergo treatment? What implications would that have in their life, long term?

So we just published in the New England Journal of Medicine that we have a major public health problem on our hands in that the majority of people leaving a garden variety of medical and surgical care have cognitive impairment that looks a lot like Alzheimer's disease or traumatic brain injury. To me, the reason that these two papers are so important is that it plays on the dignity of being human. What do they want? They want to be left with an intact brain. If they don't have an intact brain, then they question going through the suffering. And we know now that the modern-day medicine that we're providing is somehow associated with -- maybe even causing them to undergo -- this very thing that they're worried about. I think it really sets the stage for the next 20 years of medicine. We have to try and make sure that we preserve that patient's dignity and brain power, if you will, and get it back to where they were before they got sick.

9. Do you have a favorite hospital-based TV show?

I like an oldie but goodie called "St. Elsewhere." I thought that was a fabulous show. It was a very good combination of enjoyable viewing and watching people go through the reality of medicine even though it was just a TV show. A friend of mine, though, did a study on how TV describes and displays major medical interventions like codes and chest compression CPR. She published it in New England Journal of Medicine and she found that across different shows like "ER," etc., that there was a great disservice actually happening for the public in making it look like everybody survives these codes. So I think, in general, I always kind of take it with a grain of salt what we see happen in the midst of critical care on TV.

10. What is your advice to other physicians on how to avoid burnout?

Definitely keeping the patient in mind first. When you get your eye off that ball -- the ball of the patient as your primary reason for being at work that day, for leaving your family to do whatever it is that you do at the hospital -- then you're going to get burned out because you're going to be bothered by the billing and the administrative issues. The second thing is personal balance. You've got to maintain spiritual and physical balance in your life in order to survive; in order to serve your patient as well as you were trained to do. So those are the first two things. And the last thing is to preserve your conscience. You can't act against your conscience. And there's a huge debate going on in the country right now about rights of conscience. Physicians who are professionals and not just automatons, as I mentioned earlier, not just providers, have to be able to exercise their conscience.

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